Provider Demographics
NPI:1295837300
Name:MILL STREET PHARMACY INC
Entity type:Organization
Organization Name:MILL STREET PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-593-5279
Mailing Address - Street 1:10639 AL HIGHWAY 168
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957-1955
Mailing Address - Country:US
Mailing Address - Phone:256-593-5279
Mailing Address - Fax:256-593-1991
Practice Address - Street 1:10639 AL HIGHWAY 168
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-1955
Practice Address - Country:US
Practice Address - Phone:256-593-5279
Practice Address - Fax:256-593-1991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1111773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL169336Medicaid
2150239OtherPK
AL169336Medicaid
0116283OtherNABP